Download - 20091027 Cancer Colorectal
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Cáncer Cáncer ColorectalColorectal
Ernesto Martínez de la MazaInternado de PregradoHospital Ángeles del PedregalDr. Jorge Chirino
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IncidenciaIncidencia
Anualmente 945,000 personas desarrollan Cáncer colorectal.
Mujeres 2º después de Ca de mama.
Hombres 3º después de Ca pulmonar y prostático.
2ª causa de muerte en continente americano.
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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IncidenciaIncidencia5 - 6% población general 40%
muere en la enfermedad.
40 – 60 años. ◦90% > 50 años
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Factores de RiesgoFactores de Riesgo
Edad avanzada > 50 años.AHF Sxs. Hereditarios de Ca Colorectal
◦ Sx Lynch CCHNP◦ Poliposis familiar adenomatosa Relacionados con
pólipos y CáncerAHF Neoplasia. Judíos Ashkenazi (APC)Raza NegraPaíses DesarrolladosFactores Medio ambiente (estrés, Dieta,
conservadores).Obesidad
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
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Síndromes hereditariosSíndromes hereditarios
Síndromes relacionados con pólipos y cáncer.
Síndromes de poliposis hereditarias.◦Poliposis adenomatosas:
Poliposis adenomatosa familiar. Síndrome de Gardner. (Osteomatosis intestinal) Síndrome de Turcot. (glioma-poliposis)
◦Poliposis hamartomatosas: Síndrome de Peutz-Jeghers. Poliposis juvenil. Enfermedad de Cowden. (piel, mucosa oral, mama,
tiroides, intestino) Neurofibromatosis.
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Sxs.
Hereditarios de
Ca
Colorectal
Poliposis Familiar adenomatosa:◦AD◦>100 pólipos colorectales adenomatosos
pedunculados o sésiles < 1cm◦Pubertad◦Mutación gen APC
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Síndromes hereditariosSíndromes hereditarios
Carcinoma hereditario de colon no asociado a poliposis (CCHNP)
Tipo I ( sx. de Lynch tipo I ).Tipo II ( sx. de Lynch tipo II ). Sx. de Muir-Torre.
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
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Sx. LynchSx. LynchCáncer de colon hereditario no
polipomatoso.◦AD◦Ca colorectal en edades tempranas◦Gen Afectado MMR◦Colon proximal
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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Otros FactoresOtros Factores
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Riesgo en vida de Ca Riesgo en vida de Ca ColorectalColorectal
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Tamizaje y PrevenciónTamizaje y Prevención
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GenéticaGenética85% de Ca Colorectal esporádico.
◦Mutación espontánea genes supresores de tumores: P53 APC DCC
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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Carcinogénesis ColorectalCarcinogénesis Colorectal2 vías:
◦Vigilante (caretaker pathway) 15% Mutaciones o cambios epigenéticos que
mantienen estabilidad genética.
◦Encargados de puerta (Gatekeepers) 85% Genes reguladores de Crecimiento Genes
supresores de tumores y oncogenes Mutación del APC Poliposis familiar adenomatosa
Genes supresore sde Tumores DCC, DPC4/Smad4, p53, nm32.
Oncogenes K-ras, c-myc, c-neu, c-erb-2, c-src
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FisiopatologíaFisiopatología
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Cuadro ClínicoCuadro Clínico
Depende del estadío de la enfermedad y localización.◦Dolor Abdominal◦Cambios en hábito intestinal◦Anemia◦Heatoquesia
Pólipos (etapa temprana):◦Asintomáticos.
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
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Cuadro ClínicoCuadro ClínicoEtapas Avanzadas:
◦Colon Derecho: Anemia, Fatiga y debilidad
◦Colon Izquierdo: Obstrucción, cambios en el hábito
intestinal, heces con estrías de sangre.
◦Recto: Tenesmo, Hematoquezia, heces con
morfología alterada (cinta).
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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DiagnósticoDiagnósticoCOLONOSCOPÍASigmoidoscopía
FlexibleTACRMNUSG endorectalEnema de BarioCápsula endoscópica
inalámbrica
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Otros estudiosOtros estudiosSangre Oculta en heces.
Marcadores tumorales ACE ◦Poco específicos.◦Indicadores Pronósticos.
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Pólipos AdenomatososPólipos AdenomatososProliferación localizada de
epitelio displásico.◦Precursores de casi todos los Ca
Colorectales esporádicos 75%◦40% > 60 años.◦90% NO progresan a cáncer.◦Asintomátios◦H 25% / M 15% Colonoscopía
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
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Tipos de PóliposTipos de PóliposAdenomas pequeños (<0.5cm):
◦< 1 cm poca malignidad.◦> 4 cm malignidad.
Pedunculados túbulovelloso.◦Colon y Sigmoides
Sésiles MALIGNIDAD adenoma velloso. (“anémona”)◦Ciego y Recto
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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Descripción MicroscópicaDescripción MicroscópicaTubular 75% del epitelio tubular
(cañón de pistola).
Túbulo-Velloso 25 -50% Velloso, Resto tubular.
Velloso: 50% del epitelio displásico es velloso, impresiones digitales similares a velosidades en ID.
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
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Pólipo pedunculado Túbulo-Pólipo pedunculado Túbulo-vellosovelloso
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Pólipo VellosoPólipo Velloso
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EstadificaciónEstadificaciónTNMDuke´s
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TNMTNM
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EstadificaciónEstadificación
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TratamientoTratamientoQuirúrgico:
◦ Resección de segmento afectado + 5 – 10cm de colon sano.
◦ Hemicolectomía
Quimioterapia:◦ 5 Fluoracilo + Leucovorín.◦ Oxaliplatino
Radioterapia
Enfoque en proteínas oncogénicas.
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65.
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TratamientoTratamiento
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PronósticoPronósticoFactores del Paciente
◦AHF
Factores del Tumor◦Detección◦Malignidad
Factores Tratamiento◦Márgenes Resecados◦Terapéutica empleada
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718.
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Supervivencia a 5 años:Supervivencia a 5 años:
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65
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GRACIAS!!!!GRACIAS!!!!!!
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BibliografíaBibliografía
Ballinger A, Anggiansah C; Colorectal Cancer, BMJ, 2007, 335, 715 – 718
Ellenhorn D, Coia L, Alberts S, et al, editors. Colorectal and anal cancers. Coia L, Hoskins W, editors. Cancer management: a multidisciplinary approach. Melville (NY): PRR Inc; 2002.
Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008; 58(1):71–96.
Joel S. Levine, M.D., and Dennis J. Ahnen, M.D. ; Adenomatous Polyps of the Colon; NEJM; n engl j med 355;2 december 2006
Olivera J. Finn, Cancer Inmunology; N Engl J Med 2008;358:2704-15.
Weitz, Koch, Debus, Höhler, et al; Colorectal Cancer, Lancet2005; 365: 153–65